Eckerd Living Center: Missing Consent Forms - NC
Eckerd Living Center administered escitalopram oxalate 20 milligrams daily to Resident #6 under a physician order dated September 23, 2025, federal inspectors found during an April 10 visit. The facility never obtained or documented the required psychotropic medication consent form.
The resident was admitted with diagnoses of major depressive disorder and generalized anxiety disorder. Her quarterly assessment in March showed intact cognition with no behavioral symptoms.
When inspectors asked about the missing consent form, three facility managers each offered different explanations for how the requirement fell through administrative cracks.
The Nurse Team Lead, responsible for obtaining psychotropic consents, told inspectors during an 11:50 AM interview that she was "not sure what had happened." She confirmed the facility searched for but could not locate any consent documentation for Resident #6.
During a second interview at 2:05 PM, the same nurse explained her standard process: when providers issued new psychotropic orders, they gave them to her, and she obtained consent forms from residents or their responsible parties. She acknowledged this process failed in Resident #6's case.
The Director of Nursing offered a different perspective during a 3:04 PM interview. She said she "believed Resident #6 was aware of the risks and benefits of the medication because she was followed by the Psychiatric Nurse Practitioner who discussed that information with her."
But the DON acknowledged the facility could not produce any consent form and called the missing documentation "an oversight."
The Administrator provided the most revealing explanation during a 3:15 PM interview. She said the problem occurred "because there was no second check in place and once it fell through the cracks it was unknown that the consent form was missing."
She admitted the psychotropic medication consent form for Resident #6 was "forgotten and should have been documented."
Federal regulations require nursing homes to inform residents in advance about the risks and benefits of psychotropic medications and obtain documented consent before administration. The requirement exists because these medications can cause serious side effects including movement disorders, cognitive changes, and increased fall risk in elderly patients.
Escitalopram, the medication Resident #6 received, is an SSRI antidepressant that can cause side effects including nausea, drowsiness, sexual dysfunction, and withdrawal symptoms if stopped abruptly. In elderly patients, it may increase bleeding risk and interact with other medications.
The facility's medication administration records showed Resident #6 received the drug throughout March 2026, more than five months after the original order. During this entire period, her medical record contained no evidence that staff had explained the medication's purpose, potential benefits, or possible adverse effects.
The inspection revealed a systemic breakdown in the facility's consent process. The Nurse Team Lead was supposed to obtain consents when providers issued new psychotropic orders, but no backup system existed to catch oversights.
The Director of Nursing expected the Nurse Team Lead to document notifications in residents' medical records, but this documentation requirement was also missed. The Administrator's acknowledgment that "there was no second check in place" suggested the facility lacked basic quality assurance procedures for psychotropic medication management.
The violation affected few residents but represented what inspectors classified as minimal harm or potential for actual harm. However, the Administrator's admission that consent forms could fall "through the cracks" without anyone knowing raised questions about how many other residents might be receiving psychotropic medications without proper consent.
Resident #6 continued receiving escitalopram during the inspection period. The facility's inability to produce any consent documentation meant there was no record of her understanding the medication's purpose, agreeing to its use, or being informed about alternatives to drug treatment.
The Administrator stated the missing consent form "should have been completed" but provided no timeline for implementing the "second check" system she said was needed to prevent future oversights.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Eckerd Living Center from 2026-04-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
Eckerd Living Center in Highlands, NC was cited for violations during a health inspection on April 10, 2026.
The facility never obtained or documented the required psychotropic medication consent form.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Eckerd Living Center?
- The facility never obtained or documented the required psychotropic medication consent form.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Highlands, NC, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Eckerd Living Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 345437.
- Has this facility had violations before?
- To check Eckerd Living Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.